Psychiatric Emergencies

Question 1

Delirium Tremens (DTs)

Answer 1

Typically within 2-4 days after cessation of EtOH but may occur later

Delirium, agitation, fever, autonomic hyperactivity, auditory and visual hallucinations

Treat aggressively with benzodiazepines and hydration

Question 2

Neuroleptic Malignant Syndrome (NMS)

Answer 2

Fever, rigidity, autonomic instability, clouding of consciousness, elevated WBC/CPK

Withhold neuroleptics, hydrate, consider dantrolene and/or bromocriptine

Idiosyncratic, time-limited reaction

Question 3

Serotonin Syndrome

Answer 3

Precipitated by use of two drugs with serotonin-enhancing properties (e.g. MAOI + SSRI)

Altered mental status, fever, agitation, tremor, myoclonus, hyperreflexia, ataxia, incoordination, diaphoresis, shivering, diarrhea

Discontinue offending agents, benzodiazepines, consider cyproheptadine

Question 4

Tyramine Reaction/Hypertensive Crisis

Answer 4

Precipitated by ingestion of tyramine containing foods while on MAOIs

HTN, HA, neck stiffness, sweating, N/V, visual problems. Most serious consequences are stroke and possibly death

Treat with nitroprusside or phentolamine

Question 5

Acute dystonia

Answer 5

Early, sudden onset of muscle spasm: eyes, tongue, jaw, neck; may lead to laryngospasm requiring intubation

Treat with benztropine (Cogentin) or diphenhydramine (Benadryl)

Question 6

Lithium Toxicity

Answer 6

May occur at any Li level (usually over 1.5)

N/V, slurred speech, ataxia, incoordination, myoclonus, hyperreflexia, seizures, nephrogenic DI, delirium, coma

Discontinue Li, hydrate aggressively, consider HD

Question 7

Tricyclic Antidepressent (TCA) toxicity

Answer 7

Primarily anticholinergic effects: cardiac conduction disturbances, hypotension, respiratory depression, agitation, hallucinations

CNS stimulation, depression, seizures

Monitor ECG, activated charcoal, cathartics, supportive treatment